Level II Monitoring Data Entry

Health Plan Monitoring System Level I and Level II Data Entry for the Program of all-Inclusive Care for the Elderly (CMS-10525)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1264 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10525 Level II Monitoring Data Entry Form and Instruction
CMS-10525 Level Two Conference Call Worksheet LEVEL TWO CONFERENCE CALL WORKSHEET 1 TEMPLATE PRA May 1 2014.doc Form and Instruction
CMS-10525 Level Two Incident Intake Summary LEVEL TWO INCIDENT INTAKE SUMMARY TEMPLATE PRA May 1 2014(2).doc Form and Instruction

Information Collection (IC) Details

IC Title:	Level II Monitoring Data Entry	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10525	Level Two Conference Call Worksheet	LEVEL TWO CONFERENCE CALL WORKSHEET 1 TEMPLATE PRA May 1 2014.doc		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10525	Level Two Incident Intake Summary	LEVEL TWO INCIDENT INTAKE SUMMARY TEMPLATE PRA May 1 2014(2).doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	40,000	40,000
Annual IC Time Burden (Hours)	40,000	40,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.